国家质量论坛结肠癌质量指标表现：医院表现如何？

National Quality Forum Colon Cancer Quality Metric Performance: How Are Hospitals Measuring Up?

作者信息

Mason Meredith C, Chang George J, Petersen Laura A, Sada Yvonne H, Tran Cao Hop S, Chai Christy, Berger David H, Massarweh Nader N

机构信息

*Houston VA Center for Innovations In Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX †Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX ‡Departments of Surgical Oncology and Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX §Department of Medicine, Baylor College of Medicine, Houston, TX.

出版信息

Ann Surg. 2017 Dec;266(6):1013-1020. doi: 10.1097/SLA.0000000000002003.

DOI:10.1097/SLA.0000000000002003

PMID:27617852

Abstract

OBJECTIVE

To evaluate the impact of care at high-performing hospitals on the National Quality Forum (NQF) colon cancer metrics.

BACKGROUND

The NQF endorses evaluating ≥12 lymph nodes (LNs), adjuvant chemotherapy (AC) for stage III patients, and AC within 4 months of diagnosis as colon cancer quality indicators. Data on hospital-level metric performance and the association with survival are unclear.

METHODS

Retrospective cohort study of 218,186 patients with resected stage I to III colon cancer in the National Cancer Data Base (2004-2012). High-performing hospitals (>75% achievement) were identified by the proportion of patients achieving each measure. The association between hospital performance and survival was evaluated using Cox shared frailty modeling.

RESULTS

Only hospital LN performance improved (15.8% in 2004 vs 80.7% in 2012; trend test, P < 0.001), with 45.9% of hospitals performing well on all 3 measures concurrently in the most recent study year. Overall, 5-year survival was 75.0%, 72.3%, 72.5%, and 69.5% for those treated at hospitals with high performance on 3, 2, 1, and 0 metrics, respectively (log-rank, P < 0.001). Care at hospitals with high metric performance was associated with lower risk of death in a dose-response fashion [0 metrics, reference; 1, hazard ratio (HR) 0.96 (0.89-1.03); 2, HR 0.92 (0.87-0.98); 3, HR 0.85 (0.80-0.90); 2 vs 1, HR 0.96 (0.91-1.01); 3 vs 1, HR 0.89 (0.84-0.93); 3 vs 2, HR 0.95 (0.89-0.95)]. Performance on metrics in combination was associated with lower risk of death [LN + AC, HR 0.86 (0.78-0.95); AC + timely AC, HR 0.92 (0.87-0.98); LN + AC + timely AC, HR 0.85 (0.80-0.90)], whereas individual measures were not [LN, HR 0.95 (0.88-1.04); AC, HR 0.95 (0.87-1.05)].

CONCLUSIONS

Less than half of hospitals perform well on these NQF colon cancer metrics concurrently, and high performance on individual measures is not associated with improved survival. Quality improvement efforts should shift focus from individual measures to defining composite measures encompassing the overall multimodal care pathway and capturing successful transitions from one care modality to another.

摘要

目的

评估高绩效医院的护理对美国国家质量论坛（NQF）结肠癌指标的影响。

背景

NQF认可将评估≥12个淋巴结（LNs）、对III期患者进行辅助化疗（AC）以及在诊断后4个月内进行AC作为结肠癌质量指标。关于医院层面指标表现及其与生存率之间的关联数据尚不明确。

方法

对国家癌症数据库（2004 - 2012年）中218,186例接受I至III期结肠癌切除术的患者进行回顾性队列研究。通过达到各项指标的患者比例来确定高绩效医院（成就率>75%）。使用Cox共享脆弱性模型评估医院表现与生存率之间的关联。

结果

仅医院的LN表现有所改善（2004年为15.8%，2012年为80.7%；趋势检验，P < 0.001），在最近的研究年份中，45.9%的医院在所有3项指标上均表现良好。总体而言，在3项、2项、1项和0项指标上表现高绩效的医院接受治疗的患者，其5年生存率分别为75.0%、72.3%、72.5%和69.5%（对数秩检验，P < 0.001）。指标表现高绩效的医院的护理与死亡风险呈剂量反应关系降低[0项指标，作为参照；1项，风险比（HR）0.96（0.89 - 1.03）；2项，HR 0.92（0.87 - 0.98）；3项，HR 0.85（0.80 - 0.90）；2项对比1项，HR 0.96（0.91 - 1.01）；3项对比1项，HR 0.89（0.84 - 0.93）；3项对比2项，HR 0.95（0.89 - 0.95）]。指标组合的表现与死亡风险降低相关[LN + AC，HR 0.86（0.78 - 0.95）；AC + 及时AC，HR 0.92（0.87 - 0.98）；LN + AC + 及时AC，HR 0.85（0.80 - 0.90）]，而单个指标则不然[LN，HR 0.95（0.88 - 1.04）；AC，HR 0.95（0.87 - 1.05）]。